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Background

Every year, two million people become infected with the HIV virus in Africa, disproportionally affecting under 25 year olds and women. To address these challenges, governments and development partners have scaled up HIV behavior change campaigns (BCC) targeting youth. In many African countries, young women are twice as likely to be infected as young men, with transactional sex and gender-based violence as potential factors.

However, systematic reviews show that although these campaigns are often effective in increasing knowledge and improving attitudes, BCC have limited impact on reducing risky sexual behavior.

Graph 1: TV ownership (%)

50

40

30

20

10

1990 1995 2000Year

Benin

2005 20100

Cameroon EthiopiaKenya Mozambique NigeriaSenegal Tanzania Uganda

Source: Demographic Health Surveys 1987–2012.

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Other social and psychological factors can often be at play in deterring high-risk sexual behavior and gender-based violence (GBV).

The potential of introducing positive messaging in mass media programs is largely untapped. For

CHANGING BEHAVIOR THROUGH ENTERTAINMENT EDUCATION

Entertainment education could be used to positively alter attitudes and behaviors of millions of individuals at very low costs.

The MTV Shuga program substantially increased HIV testing, one of the show’s main messages.

example, 50 percent of married women in Latin America watch television every day. Two thirds listen to the radio every day. As seen in Graph 1, population surveys show that TV ownership in Sub-Sahara Africa has grown rapidly in the last two decades. Mass media programs can be informational and educational tools, especially for uneducated populations that lack access to other information sources.

The Intervention

Given the lack of results from traditional BCC, development partners are increasingly supporting entertainment education programs. Entertainment Education is a collaboration between development specialists and professorial storytellers that purposely uses mass media programs with the aim to promote positive behavior change. This approach is based on Bandura’s Social Learning Theory, which states that individuals learn through direct experience or experience of others. Media shows can allow individuals to learn from models without personal cost. Role models can lead to an improved sense of self-efficacy, the belief in one’s capabilities to organize and execute actions. Popular shows may also inform viewers about what other community members think or how they behave, which in turn may affect the viewers own attitudes and behaviors.

This impact evaluation studies the entertainment education program MTV Shuga, a TV drama produced by the MTV Staying Alive Foundation designed to raise awareness and change attitudes and behavior related to HIV/AIDS and gender-based violence among African youth. Shuga presents young Africans strata balancing bright futures from various socioeconomic with the negative consequences of high-risk behaviors. The TV drama has been broadcasted in over 70 countries, mainly in Sub Sahara Africa.

Evaluation Design

This experimental evaluation sets out to establish the impact of the MTV series Shuga on viewers’ knowledge, attitudes and risky sexual behaviors, as well as the role that social norms and peer effects play. The impact evaluation will also study the show’s indirect or spillover effects on the friends of viewers. To study the direct and indirect effects of Shuga, the research team conducted 240 community screenings in southwest Nigeria. We had over 5,000 attendees. The study design has been discussed in a TEDx Talk and a Bloomberg TV interview1. The final results will be available in the summer of 2016.

The evaluation employed a clustered randomized trial design where communities were randomly assigned to treatment and control groups. In treatment communities, individuals were shown the Shuga TV drama (Treatment 1). Control communities were shown a placebo movie that lacked messages of risky sex and GBV. In half of the treatment communities, the Shuga screenings were followed by video-clips containing information on beliefs and values of peers of the same communities after watching the Shuga drama (Treatment 2). To study the impact of watching the show with friends (peer effects), randomly selected individuals in half of both treatment arms were offered the option to bring up to two people to the screening. To study

1 https://www.youtube.com/watch?v=0mCv5U5LRG4.http://www.bloomberg.com/video/using-data-entertainment-to-combat-hiv-stigma-x47cyxH8Qi2DY8kVGZL2~A.html.

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spillovers on individuals who did not watch the TV drama, the endline surveyed friends that live in the community whom study participants regularly talk to. The primary outcomes of interest are promotion of HIV testing and reduction of gender-based violence and high-risk sexual behaviors, including transactional sex, concurrent sexual partnerships, and unprotected sex.

Preliminary Results of the Six-month follow up survey

The show was popular with viewers. The treatment group liked the show (especially women who gave it a 9.7/10 score) and became more aware of other Shuga media shows: exposure to the TV drama increased the likelihood that viewers heard about Shuga on the radio by 2.1 percent points (a 44 percent increase) and via social media by 2.5 p.p. (a 37 percent). After six months of watching Shuga, re-call about its main messages remained high. Four out of five individuals correctly remembered that the show was about HIV, and one in five recalled the themes of sugar daddies and multiple sexual partners.

Most importantly, preliminary results suggest that Shuga improved important knowledge and behavior outcomes. As seen in graph 2, despite the high knowledge levels about HIV, Shuga increased knowledge that HIV can be transmitted from a mother to her baby during pregnancy by 5.6 p.p. or 8.5% and during breastfeeding by 4.2 p.p. or 5.7%. These knowledge improvements came mainly from men. Moreover, viewers were 2.9 p.p. or 9.2% more likely to be aware of antiretroviral therapy than the control group. This result, on the other hand, was driven by female viewers.

Preliminary results show that MTV Shuga substantially increased HIV testing, one of the show’s main messages. As seen in graph 3, individuals who watched the show were 34.8% more likely to report getting tested in the last six months (9.3% versus 6.9% in the control group). These effects persisted after six months. During the follow up survey, we provided study respondents with information notes of the closest HIV testing centers. The treatment group was almost twice as likely to go to the centers and get tested (6.4% versus 3.4%). These impacts on HIV testing are large, especially when compared

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Graph 2: Knew HIV can be transmitted from a mother to her baby and Awareness of ARVs Graph 3: HIV testing (%)

80%

60%

70%

50%

40%

30%

Duringpregnancy

Bybreastfeeding

Mentioned ARV orsaid to know them

once asked explicity

Control

20%Tested less than

6 months ago(BEFORE follow up)

Went to HIVTesting center

(AFTER follow up)

6.4**

9.3*** 9.9***

7.1

3.4

6.9

Person askedhim(her)selffor the test

Treatment Control Treatment

34.4%*31.5%*

77.3%***73.1%***71.8%***

66.2%***

Source: Preliminary results, DIME Shuga Impact Evaluation.Note: Statistically significant at *** p < 0.01, ** p < 0.05, * p < 0.1.

to the effectiveness of other HIV testing promotion programs. On the other hand, there were no observed impacts on condom use.

For the next stage of the analysis, the research team will study program effects for the different treatment arms, including show impacts on GBV outcomes.

Conclusion

The preliminary results are promising, with the policy relevance being prevalent. Given the

popularity of soap operas among poorer and less educated households, entertainment education could be used to positively alter attitudes and behaviors of millions of individuals at very low costs, not only around stigmatized issues such as HIV/AIDS and gender based violence, but also around other development issues. In 2015, DIME launched a new research program in order to accelerate the evidence needed to scale up effective BCC, including entertainment-education programming (http://www.worldbank.org/en/research/dime/brief/edu-tainment).

This impact evaluation was implemented as a collaboration between Nigeria’s National Agency for the Control of AIDS, MTV Stay Alive Foundation, The Bill and Melinda Gates Foundation, the Massachusetts Institute of Technology (MIT), Bocconi University and the World Bank’s Development Impact unit (DIME). For more details on these results, please contact DIME (dime@worldbank.org).

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